Provider Demographics
NPI:1043614027
Name:FOUNTAIN SQUARE EYE CARE
Entity Type:Organization
Organization Name:FOUNTAIN SQUARE EYE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAJENDER
Authorized Official - Middle Name:
Authorized Official - Last Name:MACHA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:765-649-1200
Mailing Address - Street 1:1429 SHELBY ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46203-1946
Mailing Address - Country:US
Mailing Address - Phone:317-632-9220
Mailing Address - Fax:
Practice Address - Street 1:1429 SHELBY ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46203-1946
Practice Address - Country:US
Practice Address - Phone:317-632-9220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MACHA FAMILY EYE CARE, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-20
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002944A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty